Every finding on record at Kah Development 4, LLC

On 03/25/2024, at 12:30 PM, an Entrance Conference was conducted with Agency Representatives. The Agency was informed the purpose of the visit was to conduct a Medicare recertification survey for compliance with 42 CFR Part 484 Conditions of Participation for Home Health Agencies. On 03/28/2024, at 10:45 AM, an Exit Conference was conducted with Agency Representatives. Preliminary findings of the survey were discussed.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on Clinical Record Review and Staff Interview, it was determined the Skilled Nurse (SN) failed to include Chemotherapy Medications during the review of the patients medications in 1 of 8 Clinical Records reviewed. This failed practice by the SN posed a risk of potential harm for patients on census receiving chemotherapy medications by inhibiting the Nurse and Physicians ability to make informed decisions regarding the patients medication regimen related to potential adverse effects, drug reactions, significant side effects or significant drug interactions. Review of Clinical Record #8 revealed a document titled "Home Health Certification And Plan of Care" with a certification period from 02/17/2023 till 04/16/2024 with a diagnosis of 'Malignant Neoplasm (cancerous tumor) of Parotid Gland (salivary gland located in front of the ear)." A document titled "Client Medication Report" had an entry for "Dexamethasone 4 mg tablet with instructions stating: "Take one tablet the day before chemo and 2 days post chemo." Upon further review, no chemotherapy medications were listed on the Client Medication Report. During an interview on 03/28/2024 at 11:07 AM, Agency Representatives were provided an opportunity to present additional documentation. Agency Personnel #1 confirmed Agency staff did not include Chemotherapy Medications the patient is currently using during a review of all medications. Agency Personnel #1 stated, " The Nurse overlooked getting those medications from the oncologists (cancer doctor) office.

. On 09/07/21 at 11:40 AM, an entrance conference was conducted with Agency Representatives. The Agency was informed the purpose of the visit was to conduct a Medicare Recertification survey for compliance with the Conditions of Participation for Home Health. On 09/10/21 at 12:15 PM an exit conference was conducted with Agency Representatives. Preliminary findings of the survey were discussed. .

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: . Based on Clinical Record review and staff interviews, it was determined the Skilled Nurse (SN) staff did not accurately document care provided including all interventions in 1 (#1) of 7 (#1 - #7) Clinical Records reviewed. The deficient practice identified, resulted in an inaccurate and incomplete Clinical Record and if continued had the potential to inhibit interventions according to doctors' orders and attainment of goals specific to the patients needs. Findings follow: . Findings 1. Review of Clinical Record #1 revealed a Plan of Care (POC) with a Certification period of 07/09/21 through 09/06/21. The POC contained orders for the "Skilled Nurse to insert/change/maintain indwelling catheter, 16 FR 10 ML Balloon.". Review of a document titled "Visit Note Report" dated 07/27/21 revealed documentation "performed indwelling catheter insertion/change....Inserted indwelling catheter/ 18 FR/10 ml balloon". 2. During staff interview on 09/10/21 at 8:30 AM, staff member #1 stated, " I believe this was a documentation error. Looking at the patient's supply requisitions from (named supply company), the nurses have ordered only 16 FR 10 ml Foley catheters for this patient." Staff #1 confirmed the SN documented the incorrect sized catheter on 07/27/21 visit.